Insertion of Peripheral IV Line

Peripheral IV line and cannula insertion is a medical procedure under IV Therapy or Intravenous therapy. It’s purpose is to introduce fluid, medicine, or blood (as in blood transfusion) directly into the veins by providing a passage.

Overview

Many patients in the medical and surgical wards will have some form of Intravenous Therapy. This can range from an intravenous infusion with or without an infusion pump, intravenous cannula with an injection port, through to a central venous line. This therapy provides a direct route to the bloodstream which allows for hydration, administration of blood or blood products and administration of medications. Medications that are administered intravenously bypass the normal means of absorption associated with oral, topical, rectal, sub cutaneous or intra muscular administration. Therefore, drugs administered intravenously achieve therapeutic level very rapidly and frequently a lower dose is required.

Various intravenous cannula

The picture shows various intravenous cannula. These are inserted into the vein, often in the lower arm. The different colors represent different internal diameter (gauges) of the cannula. Fine bore cannula are usually used in children, larger bore for adults. If a large amount of fluid is required to be administered over a short time period a large bore cannula is used.

Contraindications

Avoid extremities that have massive edema, burns, or injury; in these cases other IV sites need to be accessed.

Avoid going through an area of cellulitis; the area of infection should not be punctured with a needle because of the risk of inoculating deeper tissue or the bloodstream with bacteria.

Avoid extremities with an indwelling fistula; it is preferable to place the IV in another extremity because of changes in vascular flow secondary to the fistula.

An upper extremity on the same side of a mastectomy should be avoided, particularly if an axillary node dissection was carried out, because of concerns of previous lymphatic system damage and adequate lymphatic flow.

Very short procedures performed on pediatric patients, like placement of ear tubes

Key points

1. Only nurses who have been certified as competent in the insertion of IV cannula will
perform this procedure.
2. Where the patient is less than 14 years of age, the IV cannula will be inserted by a medical practitioner. The exception will be in the case of neonates where neonatal trained nurses may insert an IV cannula if directed by a medical officer.
3. In the case of two unsuccessful attempts at insertion, the operator will seek the assistance of another experienced nurse for one additional attempt. After a total three unsuccessful attempts, the assistance of a medical practitioner will be sought.

Selection of Equipment

1. Select cannula based on purpose and duration of use, and age of patient.
2. Consider risk of infection and extravasation.
3. Cannulae made from polyurethanes are associated with decreased risk of phlebitis.
4. Steel needles have higher risk of extravasation and should be avoided where tissue necrosis is likely if extravasation occurs.

Skin prep

Antiseptic solution – 70% isopropyl alcohol, 0.5 – 1% Chlorhexidine
Use an aqueous based alternative if there is a known allergy to alcohol.

1. EMLA cream can usually make the insertion of a central or peripheral intravenous cannula or scalp vein needle painless. The use of EMLA however requires planning as the cream must be applied at least one hour and preferably one and a half hours before the proposed procedure. It is therefore suitable for elective procedures but not for emergencies.
2. EMLA will be effective for up to four hours from the time of application, and penetration may continue for 30 minutes after removal.
3. EMLA is not recommended for infants under 3 months of age. Premature infants should be at least 52 weeks post conception before the use of EMLA cream is considered.

Selection of Catheter Site

Choose a suitable vein. In adults, use long straight veins in an upper extremity away from the joints for catheter insertion – in preference to sites on the lower extremities. If possible avoid veins in the dominant hand and use distal veins first.

Do not insert cannula on the side of mastectomy or AV shunts/Gortex. Transfer catheter inserted in a lower extremity site to an upper extremity site as soon as the latter is available.

In pediatric patients, it is recommended that the cannula be inserted into the scalp, hand, or foot site in preference to a leg, arm, or ante cubital fossa site (Category II).

Procedure

Note: To be able to insert an IV cannula, the practitioner will be required to be at least practicing as an RN or EN, complete with a competency assessment.

The first thing that must be done is to have a signed order for the Intravenous fluid. This is found on the Fluid Treatment Chart.

Intravenous fluid treatment chart

Make sure to follow the order, unless contraindicated.

The chart above has an order for 500 mL of 5% Dextrose (often written as D5W) over 8 hours, commencing at 1400 hours. Normally the date is recorded, this chart says Today in the date column, this is just an example. A real Fluid Treatment Chart should contain the real date. The order is not signed by the Nurse as it has not been given yet.

Usually it is prepared in a clean room. Prior to priming the line, it is important to check the following with another RN:

patient name

IV fluid against the ordered fluid

expiry date and clarity of fluid

Prior to connecting the primed IV to a patient, the following must be checked against the Fluid Treatment Chart:

written signed order

patient ID

correct fluid

date and time – often no time is documented – the nurse completes time when IV started

Nursing Care

Before injecting medication into an IV or before connecting a new fluid bag to the IV, cleanse the port site with an alcohol swab (70% alcohol) and allow to air-dry.

Evaluate the IV site at the time of new injections and regularly to ensure that no infiltration has occurred and that IV injection agents are intravascular, not subcutaneous.

Evaluate the IV site daily for evidence of infection: rubor (redness), calor (warmth), dolor (pain), and tumor (swelling). Palpate the site to ensure that there is no pain near or around the catheter. If the site is covered by tape and there is tenderness at the catheter site, remove the tape to evaluate the catheter site.

If evidence of infection exists, remove the IV catheter and place another in a different location.

Encourage patients to report any changes or discomfort at the catheter site.

Antibiotic prophylaxis (oral or topical) is not indicated for peripheral IV indwelling catheters.

If an IV does not have a constant infusion flowing through the tubing, anticoagulant flush solutions are used in catheters to prevent thrombi and fibrin deposits. A commonly used solution is 5 mL of saline with 10 U/mL heparin.

Change the catheter site dressing immediately if the dressing is loose, wet, or visibly soiled.

Promptly remove any intravascular catheter that is no longer essential.

Replace peripheral venous catheters at least every 72 to 96 hours in adults to prevent phlebitis. Leave peripheral venous catheters in place in children until IV therapy is completed, unless complications (e.g., phlebitis and infiltration) occur.

When adherence to aseptic technique cannot be ensured (e.g., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and after no longer than 48 hours.

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On may 28 I went into the hospital in the er they put in a IV into my rist it hurt really bad taken out next morning. It got infected gave me antibiotics for a week. I told the Dr every time I move it it hurts and now when I Go to use it it hurts more every day. Could something have come off when the IV was put in? Any advice would be helpful. Thanks